HF Exposure Treatment Guide - Honeywell Hydrofluoric Acid

Honeywell Hydrofluoric Acid
HF Products
For additional information
Hydrofluoric Acid Treatment
Quick Reference Chart
FOLD OUT HERE
For additional assistance, including
technical information covering all
aspects of hydrofluoric acid, safe
handling, use and disposal write:
Honeywell Performance Materials
and Technologies
Fluorine Products
101 Columbia Road
Morristown, NJ 07962-1053
This booklet describes the special First Aid and Medical Treatment measures
necessary following exposure to or injury from HYDROFLUORIC ACID (HF).
In the event of a medical emergency
with this product, call the 24-hour
However, it must be emphasized that
Honeywell emergency telephone number:
800-498-5701
PREVENTION
of exposure or injury must be the primary goal.
To place an order, obtain prices or product availability information, call toll-free:
Preventive measures include:
From within the continental United States
800-522-8001
1. Making everyone who handles or uses HF aware of its properties
973-455-6300
and dangers.
From any location in Canada
2. Training everyone who uses HF in proper handling and safety precautions.
800-553-9749
3. Utilizing all appropriate engineering controls, and making sure that the
controls are maintained and functioning properly.
4. Requiring everyone who handles or uses HF to have available the proper
safety and personal protective equipment, to be trained to use the
equipment, and to always use the equipment when necessary.
5. Arranging ahead of time to provide first aid or medical treatment
Recommended Medical Treatment
for Hydrofluoric Acid Exposure
measures if necessary.
If you have questions, comments or suggestions, please write to:
Technical Service Manager - Hydrofluoric Acid
Honeywell Performance Materials and Technologies
101 Columbia Road
Morristown, New Jersey 07962-1053
Honeywell Performance Materials
and Technologies
101 Columbia Road
Morristown, NJ 07962
Toll Free: 1-800-622-5002
Fax: 1-973-455-6141
www.honeywell.com/hfacid
FP-003
DISCLAIMER: All statements, information, and data given herein are
believed to be accurate and reliable but are presented without guaranty, warranty, or responsibility of any kind, express or implied.
Statements or suggestions concerning possible use of our products
are made without representation or warranty that any such use is free
of patent infringement and are not recommendations to infringe any
patent. The user should not assume that all medical and first aid
measures are indicated or that other measures may not be required.
October 2012
Printed in USA
© 2012 Honeywell International Inc.
All rights reserved
Treatment of Hydrofluoric Acid (HF) Exposure
Quick Reference
SKIN BURNS
NOTE: In addition to the usual medical history, the physician should obtain the following information: concentration
of HF, date and time of exposure, duration of exposure, how exposure occurred, body parts exposed/affected, first
aid measures instituted (what, when, how long). Injuries due to dilute HF solutions or low concentrations of
vapors may result in delays in clinical presentation up to 24 hours following exposure.
EYE EXPOSURE
FIRST AID
INHALATION
CONCENTRATED HF
DILUTE HF
ALL HF
CONCENTRATED HF
Water Wash
THEN
Iced Benzalkonium Chloride*
0.13% Soaks
OR
Calcium Gluconate
2.5% Gel
Water Wash
THEN
Iced Benzalkonium Chloride*
0.13% Soaks
OR
Calcium Gluconate
2.5% Gel
Water Wash
OR
Saline Wash
Oxygen
AND
2.5% Calcium Gluconate4
by Nebulizer
INGESTION
(Mild Exposures)
DILUTE HF
ALL HF
DO NOT INDUCE VOMITING
Oxygen
THEN
Consider
2.5% Calcium Gluconate4
by Nebulizer
Milk or Water
THEN
Milk of Magnesia
OR
Any Calcium
Containing Antacid
MEDICAL TREATMENT
CONCENTRATED HF
DILUTE HF
ALL HF
CONCENTRATED HF
DILUTE HF
ALL HF
Debride (if necessary)
THEN
Continue Soaks
OR
Calcium Gluconate
2.5% - 5% Injection2,4
AND
Observe for/Treat
Systemic Effects3
(especially if > 25 sq. in.)
Debride (if necessary)
THEN
Continue Soaks
OR
Calcium Gluconate
2.5% Gel
OR
Calcium Gluconate
2.5% - 5% Injection2,4
Systemic Effects3 Unlikely
Topical Tetracaine
Hydrochloride
THEN
1% Calcium
Gluconate Irrigation4
AND
Consult
Opthamologist
Continue Calcium
Gluconate by Nebulizer
Continue Calcium by
Gluconate Nebulizer
Lavage with
Calcium Chloride
or Calcium Gluconate
AND
Treat Systemic Effects3
1. This is a brief summary of First Aid and Medical
Treatment measures. The text of the brochure
“RECOMMENDED MEDICAL TREATMENT FOR
HYDROFLUORIC ACID EXPOSURE” must be
consulted for more complete information.
2. 2.5% - 5% calcium gluconate injections must be used
if the soaks or gel do not significantly relieve pain in
30-40 minutes. Injections may also be used as the
primary treatment, especially for larger and/or
deeper burns.
3. Systemic effects include hypocalcemia,
hypomagnesemia, hyperkalemia, cardiac arrhythmias,
and altered pulmonary hemodynamics. TREATMENT
includes cardiac monitoring, monitoring serum calcium,
fluoride, magnesium, and electrolytes; administration of
IV calcium gluconate, correcting magnesium and
electrolyte imbalance, and, in extreme cases,
hemodialysis.
4. Calcium gluconate is normally supplied in ampules
containing 10% calcium gluconate. Concentrations less
than 10% are obtained by diluting with normal saline.
Observe and Treat
for
Respiratory Distress,
Bronchoconstriction,
Pulmonary Edema,
Systemic Effects3
(Inhaled Steroids and/or
Bronchodialators as Needed)
Observe
Serious Effects Unlikely
Inhalation of HF Fumes
from Diluted Acid is
Uncommon
For additional reference charts or information on properties,
storage and handling, or medical treatment for
hydrofluoric acid, contact:
Honeywell Performance Materials
and Technologies
101 Columbia Road
Morristown, NJ 07962
In the event of a medical emergency with this product, call
the 24-hour Honeywell emergency telephone number:
* Benzalkonium chloride is a high molecular weight quaternary ammonium compound available as Zephiran® a Registered Trademark of Sanofi Pharmaceuticals, New York, NY 10016
+ Registered trademark, Johnson & Johnson - Merck, Fort Washington, PA 19034
All statements, information, and data given herein are believed to be accurate and
reliable but are presented without guaranty, warranty, or responsibility of any kind,
express or implied. Statements or suggestions concerning possible use of our products are
made without representation or warranty that any such use is free of patent infringement
and are not recommendations to infringe any patent. The user should not assume that all
medical and first aid measures are indicated or that other measures may not be required.
800-498-5701
This foldout chart is also available as
a laminated 15” x 23” wall poster.
Honeywell Hydrofluoric Acid
HF Products
For additional information
Hydrofluoric Acid Treatment
Quick Reference Chart
FOLD OUT HERE
For additional assistance, including
technical information covering all
aspects of hydrofluoric acid, safe
handling, use and disposal write:
Honeywell Performance Materials
and Technologies
Fluorine Products
101 Columbia Road
Morristown, NJ 07962-1053
This booklet describes the special First Aid and Medical Treatment measures
necessary following exposure to or injury from HYDROFLUORIC ACID (HF).
In the event of a medical emergency
with this product, call the 24-hour
However, it must be emphasized that
Honeywell emergency telephone number:
800-498-5701
PREVENTION
of exposure or injury must be the primary goal.
To place an order, obtain prices or product availability information, call toll-free:
Preventive measures include:
From within the continental United States
800-522-8001
1. Making everyone who handles or uses HF aware of its properties
973-455-6300
and dangers.
From any location in Canada
2. Training everyone who uses HF in proper handling and safety precautions.
800-553-9749
3. Utilizing all appropriate engineering controls, and making sure that the
controls are maintained and functioning properly.
4. Requiring everyone who handles or uses HF to have available the proper
safety and personal protective equipment, to be trained to use the
equipment, and to always use the equipment when necessary.
5. Arranging ahead of time to provide first aid or medical treatment
Recommended Medical Treatment
for Hydrofluoric Acid Exposure
measures if necessary.
If you have questions, comments or suggestions, please write to:
Technical Service Manager - Hydrofluoric Acid
Honeywell Performance Materials and Technologies
101 Columbia Road
Morristown, New Jersey 07962-1053
Honeywell Performance Materials
and Technologies
101 Columbia Road
Morristown, NJ 07962
Toll Free: 1-800-622-5002
Fax: 1-973-455-6141
www.honeywell.com/hfacid
FP-003
DISCLAIMER: All statements, information, and data given herein are
believed to be accurate and reliable but are presented without guaranty, warranty, or responsibility of any kind, express or implied.
Statements or suggestions concerning possible use of our products
are made without representation or warranty that any such use is free
of patent infringement and are not recommendations to infringe any
patent. The user should not assume that all medical and first aid
measures are indicated or that other measures may not be required.
October 2012
Printed in USA
© 2012 Honeywell International Inc.
All rights reserved
Treatment of Hydrofluoric Acid (HF) Exposure
Quick Reference
SKIN BURNS
NOTE: In addition to the usual medical history, the physician should obtain the following information: concentration
of HF, date and time of exposure, duration of exposure, how exposure occurred, body parts exposed/affected, first
aid measures instituted (what, when, how long). Injuries due to dilute HF solutions or low concentrations of
vapors may result in delays in clinical presentation up to 24 hours following exposure.
EYE EXPOSURE
FIRST AID
INHALATION
CONCENTRATED HF
DILUTE HF
ALL HF
CONCENTRATED HF
Water Wash
THEN
Iced Benzalkonium Chloride*
0.13% Soaks
OR
Calcium Gluconate
2.5% Gel
Water Wash
THEN
Iced Benzalkonium Chloride*
0.13% Soaks
OR
Calcium Gluconate
2.5% Gel
Water Wash
OR
Saline Wash
Oxygen
AND
2.5% Calcium Gluconate4
by Nebulizer
INGESTION
(Mild Exposures)
DILUTE HF
ALL HF
DO NOT INDUCE VOMITING
Oxygen
THEN
Consider
2.5% Calcium Gluconate4
by Nebulizer
Milk or Water
THEN
Milk of Magnesia
OR
Any Calcium
Containing Antacid
MEDICAL TREATMENT
CONCENTRATED HF
DILUTE HF
ALL HF
CONCENTRATED HF
DILUTE HF
ALL HF
Debride (if necessary)
THEN
Continue Soaks
OR
Calcium Gluconate
2.5% - 5% Injection2,4
AND
Observe for/Treat
Systemic Effects3
(especially if > 25 sq. in.)
Debride (if necessary)
THEN
Continue Soaks
OR
Calcium Gluconate
2.5% Gel
OR
Calcium Gluconate
2.5% - 5% Injection2,4
Systemic Effects3 Unlikely
Topical Tetracaine
Hydrochloride
THEN
1% Calcium
Gluconate Irrigation4
AND
Consult
Opthamologist
Continue Calcium
Gluconate by Nebulizer
Continue Calcium by
Gluconate Nebulizer
Lavage with
Calcium Chloride
or Calcium Gluconate
AND
Treat Systemic Effects3
1. This is a brief summary of First Aid and Medical
Treatment measures. The text of the brochure
“RECOMMENDED MEDICAL TREATMENT FOR
HYDROFLUORIC ACID EXPOSURE” must be
consulted for more complete information.
2. 2.5% - 5% calcium gluconate injections must be used
if the soaks or gel do not significantly relieve pain in
30-40 minutes. Injections may also be used as the
primary treatment, especially for larger and/or
deeper burns.
3. Systemic effects include hypocalcemia,
hypomagnesemia, hyperkalemia, cardiac arrhythmias,
and altered pulmonary hemodynamics. TREATMENT
includes cardiac monitoring, monitoring serum calcium,
fluoride, magnesium, and electrolytes; administration of
IV calcium gluconate, correcting magnesium and
electrolyte imbalance, and, in extreme cases,
hemodialysis.
4. Calcium gluconate is normally supplied in ampules
containing 10% calcium gluconate. Concentrations less
than 10% are obtained by diluting with normal saline.
Observe and Treat
for
Respiratory Distress,
Bronchoconstriction,
Pulmonary Edema,
Systemic Effects3
(Inhaled Steroids and/or
Bronchodialators as Needed)
Observe
Serious Effects Unlikely
Inhalation of HF Fumes
from Diluted Acid is
Uncommon
For additional reference charts or information on properties,
storage and handling, or medical treatment for
hydrofluoric acid, contact:
Honeywell Performance Materials
and Technologies
101 Columbia Road
Morristown, NJ 07962
In the event of a medical emergency with this product, call
the 24-hour Honeywell emergency telephone number:
* Benzalkonium chloride is a high molecular weight quaternary ammonium compound available as Zephiran® a Registered Trademark of Sanofi Pharmaceuticals, New York, NY 10016
+ Registered trademark, Johnson & Johnson - Merck, Fort Washington, PA 19034
All statements, information, and data given herein are believed to be accurate and
reliable but are presented without guaranty, warranty, or responsibility of any kind,
express or implied. Statements or suggestions concerning possible use of our products are
made without representation or warranty that any such use is free of patent infringement
and are not recommendations to infringe any patent. The user should not assume that all
medical and first aid measures are indicated or that other measures may not be required.
800-498-5701
This foldout chart is also available as
a laminated 15” x 23” wall poster.
Table of Contents
INTRODUCTION...................................................................................................................................................2
ACUTE TOXICITY..................................................................................................................................................2
Skin Contact.......................................................................................................................................................2
Systemic Toxicity................................................................................................................................................3
Eye Contact........................................................................................................................................................3
Inhalation............................................................................................................................................................4
Ingestion.............................................................................................................................................................4
CHRONIC TOXICITY.............................................................................................................................................4
FIRST AID TREATMENT FOR HYDROFLUORIC ACID BURNS................................................................5
Skin Contact.......................................................................................................................................................5
Eye Contact........................................................................................................................................................6
Inhalation............................................................................................................................................................6
Ingestion..........................................................................................................................................................6
MEDICAL TREATMENT FOR HYDROFLUORIC ACID BURNS...............................................................7
Burns of the Skin – General................................................................................................................................7
Quaternary Ammonium Compounds...............................................................................................................7
Calcium Gluconate Gel....................................................................................................................................8
Calcium Gluconate Injections..........................................................................................................................8
Calcium Gluconate Solution.............................................................................................................................8
Burns of the Fingers and Nails.........................................................................................................................8
Intra-arterial and Intravenous Calcium Infusion................................................................................................9
Additional Measures.........................................................................................................................................9
Additional and Unproven Therapies................................................................................................................10
Systemic Absorption and Metabolic Effects....................................................................................................10
Hemodialysis....................................................................................................................................................11
Eye Injuries.......................................................................................................................................................11
Inhalation Injuries.............................................................................................................................................11
Ingestion Injuries..............................................................................................................................................12
REFERENCES....................................................................................................................................................13
APPENDIX......................................................................................................................................................14
WARNING: BURNS WITH CONCENTRATED HF ARE USUALLY VERY SERIOUS, WITH THE POTENTIAL FOR
SIGNIFICANT COMPLICATIONS DUE TO FLUORIDE TOXICITY. CONCENTRATED HF, LIQUID OR VAPOR
MAY CAUSE SEVERE BURNS, METABOLIC IMBALANCES, PULMONARY EDEMA AND LIFE THREATENING
CARDIAC ARRYTHMIAS. EVEN MODERATE EXPOSURES TO CONCENTRATED HF MAY RAPIDLY
PROGRESS TO FATALITY IF LEFT UNTREATED.
1
The recommended medical procedures described in this
Introduction
brochure are based on a review of the available literature,
shared experiences with others who have dealt with the health
Because the medical treatment of hydrofluoric acid
effects of HF, the personal knowledge and experiences of
exposure is so specialized and differs from the treatment
Honeywell physicians, nurses and other professionals in
of other inorganic acid exposures, physicians may be unaware
dealing with the unique hazards of this product, and
of appropriate treatment measures. It is recommended that HF
experimental laboratory work sponsored by Honeywell.
users ensure ahead of time that their local medical resources
are familiar with the toxicity of HF and the treatment of HF
Every effort must be made to prevent exposure to HF. If
exposure. This would include, at a minimum, thoroughly reviewing
exposure does occur, the specialized procedures which
this booklet and making sure that treatment facilities and supplies
follow are recommended to avoid the very serious
are available.
consequences that might otherwise occur.
Hydrofluoric acid (CAS # 7664-39-3) is very aggressive
Acute Toxicity
physiologically because of the fluoride ion. Both anhydrous
hydrofluoric acid (hydrogen fluoride) and its solutions are clear,
SKIN CONTACT
colorless liquids. When exposed to air, concentrated solutions
and anhydrous hydrofluoric acid produce pungent fumes which
are especially dangerous. Unless heated, dilute concentrations
HF can cause serious, painful burns of the skin. Specialized
of hydrofluoric acid in water (e.g., less than 40% HF) do not
first aid and medical treatment is required. Burns larger than
25 square inches (160 square cm) may result in serious
produce significant vapor concentrations.
systemic toxicity.
NOTE: Persons unfamiliar with hydrofluoric acid often mistake it
HF is a highly corrosive acid which can severely burn skin,
for, or confuse it with, hydrochloric acid. Although hydrofluoric acid
(HF) and hydrochloric acid (HCl) have similar sounding names,
eyes, and mucous membranes. The vapors from anhydrous
the toxicity of these two acids is very different. To decrease or
hydrofluoric acid or its concentrated solutions can also burn
avoid confusion, we recommend that HYDROFLUORIC ACID
these tissues.
and HYDROGEN FLUORIDE be referred to as "HF".
HF is similar to other acids in that the initial extent of a burn
depends on the concentration, the temperature, the duration of
HF is primarily an industrial raw material. It is used in
fluorocarbon production, stainless steel manufacturing, metal
contact with the acid and the size of the burn. Hydrofluoric
finishing, aluminum manufacturing, inorganic and organic
acid differs, however, from other acids because the fluoride
chemical manufacturing, petroleum refining, mineral processing,
ion readily penetrates the skin, causing destruction of deep
glassmaking and electronic components manufacturing. It
tissue layers. Unlike other acids which are rapidly neutralized,
is also used in certain industrial and consumer cleaning
this process may continue for days if left untreated.
compounds. However, its use in consumer products is
Strong acid concentrations (over 50%), and particularly
discouraged because of its potential toxicity.
anhydrous HF (AHF or 100% HF), cause immediate,
Most non-industrial burns are caused by dilute concentrations
severe, burning pain and a whitish discoloration of
of HF (e.g, less than 15% HF). Most of the HF used in the
the skin often followed by blister formation. Skin exposure
electronics industry is less than 50%. However, many
to HF vapors can result in similar burns.
industrial uses of HF involve concentrated (50-100%) HF.
HF skin burns are usually accompanied by severe, throbbing
WARNING: BURNS WITH CONCENTRATED HF ARE USUALLY
pain which is thought to be due to irritation of nerve endings
VERY SERIOUS, WITH THE POTENTIAL FOR SIGNIFICANT
by increased levels of potassium ions entering the extracellular
COMPLICATIONS DUE TO FLUORIDE TOXICITY.
space to compensate for the reduced levels of calcium ions,
CONCENTRATED HF, LIQUID OR VAPOR, MAY CAUSE
which have been bound to the fluoride. Relief of pain is an
SEVERE BURNS, METABOLIC IMBALANCES, PULMONARY
important guide to the success of treatment.
EDEMA AND LIFE THREATENING CARDIAC ARRYTHMIAS.
EVEN MODERATE EXPOSURES TO CONCENTRATED HF MAY
The usual initial signs of an HF burn are redness, edema, and
RAPIDLY PROGRESS TO FATALITY IF LEFT UNTREATED.
blistering. With more concentrated acids, a blanched white
2
area appears. The fluoride ion penetrates the upper layers of
This process releases energy, and therefore occurs very
the skin. A thick granular exudate may form under blisters
readily. The toxic effect of HF on body calcium is certainly
due to liquefaction necrosis. In rare (and untreated) cases,
more complicated than this. There is some evidence that
there may be penetration to underlying bone with decalcification.
fluoride may combine with calcium and phosphate, so that
HF burns require immediate and specialized first aid and
five calcium ions are tied up for each fluoride ion (e.g.
medical treatment (2, 3, 4, 5, 6, 7) differing from the
Ca5F(PO4)3), rather than two. There is also some evidence
treatment of other chemical burns. If untreated or if
that there may be high intracellular levels of calcium in some
improperly treated, permanent damage, disability or
tissues, rather than low levels, as would intuitively be expected.
death may result. (8) If, however, the burns are promptly
(16) However, the reaction of fluoride with body calcium is
and properly recognized and managed, the results of
one of the major toxic effects and forms the basis for many
treatment are generally favorable.
treatment recommendations.
Treatment is directed toward binding the fluoride ions
One of the most serious consequences of severe exposure to
to prevent tissue destruction. High molecular weight
HF by any route is the marked lowering of serum calcium
quaternary ammonium compounds, e.g. benzalkonium
(hypocalcemia) and other metabolic changes, which may
chloride (Zephiran®), are used as soaking agents. (9, 10,
result in a fatal outcome if not recognized and treated.
11) Calcium gluconate as a gel or ointment can be applied
Hypocalcemia should be considered a potential risk in all
locally, and calcium gluconate solution may be injected
instances of inhalation or ingestion, and whenever skin
(subcutaneously, intravenously, or intra-arterially), inhaled,
burns exceed 25 square inches, (160 square centimeters).
or used as an irrigant. (3, 12, 13, 14, 15)
Serum magnesium may also be lowered, and elevations in
serum potassium have been reported to further complicate
Speed is of the essence. Delays in first aid care or medical
the metabolic imbalances which need to be monitored and
treatment or improper medical treatment will likely result in
corrected. (16, 17, 18) High levels of fluorides have been
greater damage or may, in some cases, result in a fatal
noted both in the blood and body organs. Hemodialysis has
outcome. During transportation to a medical facility or
been reported to be effective therapy for cases of severe
while waiting for a physician to see the victim, it is
systemic flouride intoxication. (19, 20, 21) Treatment for shock
extremely important to continue the benzalkonium
may also be required as for other severe injuries.
chloride (Zephiran) soaks or compresses or continue
massaging calcium gluconate gel. In contrast to the
Other effects reported from fluoride exposure include
immediate effects of concentrated HF, the effects of contact
coagulation defects and inhibition of a number of enzymes,
with more dilute hydrofluoric acid or its vapors may be
including preglycolytic enzymes, phosphatases and
delayed, and this is one of the problems with the recognition
cholinesterase. The results of this enzyme inhibition include
of some HF burns. Skin contact with acid concentrations in
inhibition of cellular glucose phosphorylation and subsequent
the 20% to 50% range may not produce clinical signs or
glycolysis, inhibition of respiration, and increased sensitivity
symptoms for one to eight hours. With concentrations less
of cholinergic mechanisms to acetyl cholinesterase. (22)
than 20%, the latent period may be up to twenty-four hours.
While hypocalcemia has been traditionally considered the
HF concentrations as low as 2% may cause symptoms if the
major systemic effect of severe poisoning with HF, it is
skin contact time is long enough. (1)
apparent that hypomagnesemia, hyperkalemia, the cardiode-
SYSTEMIC TOXICITY
pressing and vasodilating effects of fluoride and effects on
pulmonary hemodynamics and systemic capacitance vessels,
To produce HF, calcium fluoride is reacted with sulfuric acid:
including an increase in pulmonary vascular resistance, all
play a role in systemic toxicity. Although some of these effects
CaF2 + H2SO4
2HF + CaSO4
have been described, the implications for therapeutic
measures have not been well defined. (23, 24)
This production process requires a great deal of energy to
EYE CONTACT
accomplish. On the other hand, in the body:
2HF + Ca++
CaF2
Hydrofluoric acid can cause severe eye burns with destruction
or opacification of the cornea. Blindness may result from
3
severe or untreated exposures. Immediate first aid and
which nearly all individuals could be exposed up to one hour
specialized medical care is required. (3,13)
without experiencing other than mild, transient adverse health
effects (ERPG-1). (29)
INHALATION
The California Occupational Safety and Health Standards
Hydrofluoric acid fumes may cause laryngospasm, laryngeal
Board has established a PEL of 0.4 ppm 8hr TWA
edema, bronchospasm and/or acute or delayed pulmonary
[.33mg/m3] with a STEL (Short term exposure level) of
edema. Acute symptoms may include coughing, choking,
1 ppm [0.83mg/m3]. (32)
chest tightness, chills, fever and cyanosis. Many reported
INGESTION
fatalities from HF exposures have been due to severe pulmonary edema (coupled with systemic toxicity) that did not
Ingestion of HF may result in severe burns to the mouth,
respond to usual medical treatment.
esophagus and stomach. Severe systemic effects are
Burns from vapors or liquid contact to the oropharyngeal
common. Ingestion of even small amounts of dilute HF have
mucosa or upper airway may cause severe swelling to the
resulted in death. (30)
point of requiring a tracheostomy. It is recommended that all
patients with such exposures be hospitalized for observation
Toxic myocarditis, believed to be associated with HF Acid
and/or treatment.
ingestion with a suicide attempt has been reported. (5)
Because of the strong irritant nature of HF, an individual
Chronic Toxicity
inhaling HF vapors or fumes will usually experience upper
respiratory injury, with mucous membrane irritation and
Because it is a strong irritant there are few exposures to HF
inflammation as well as cough. All individuals suspected of
having inhaled HF should be observed for pulmonary effects.
sufficient to suggest risk of chronic toxicity. HF has not been
This would include those individuals with significant upper
the subject of long term toxicity studies or testing. Once HF
respiratory irritation, bronchoconstriction by pulmonary
enters the body, it is expected that the fluoride ion would be
auscultation or spirometry, and any individual with HF
the major concern from a chronic toxicity standpoint. Chronic
exposure to the head, chest or neck areas. It has been
toxicity from long term, high exposure to fluoride salts (eg.
reported that pulmonary edema may be delayed for several
SnF2, NaF, Na2 FPO3) has been reported to result in tooth
hours and even up to two days. If there is no initial upper
mottling in children, bone fluorosis and sometimes
respiratory irritation, significant inhalation exposure can
osteosclerosis in adults and children.
generally be ruled out.
Skeletal fluorosis is known to be associated with excessive
The Permissible Exposure Limit (PEL) set by the U.S.
exposure to fluoride compounds. Cases of skeletal
Occupational Safety and Health Administration (OSHA) is a
fluorosis have been reported in populations exposed to
time weighted average exposure for 8 hours of 3 ppm. (25)
naturally occurring drinking water containing greater than
The American Conference of Governmental Industrial
10 ppm of fluoride ion and in individuals exposed to high
Hygienists (ACGIH) recommends a ceiling level of 2 ppm or
levels of fluoride containing dusts. However, skeletal
1.53 mg/m3 with a 0.5 ppm TLV-TWA. (26) The National
fluorosis has not been reported as a consequence of
Institute for Occupational Safety and Health (NIOSH) has
HF exposure.
established the level that is immediately dangerous to life
and health (IDLH) at 30 ppm. (27, 28) The American
Because of the use of fluoride to prevent dental caries,
Industrial Hygiene Association has published an Emergency
there is ongoing evaluation of fluorides for the potential to
Response Planning Guideline setting 50 ppm as the
cause cancer. There is no evidence that fluoride is genotoxic
maximum level below which nearly all individuals could be
except in some in vitro assays at cytotoxic concentrations.
exposed for one hour without experiencing or developing
Epidemiological studies have not demonstrated an association
life-threatening health effects (ERPG-3), 20 ppm as the
between fluoride in drinking water and an increase in cancer.
maximum level below which nearly all individuals could be
The International Agency for Research on Cancer (IARC)
exposed for one hour without developing irreversible health
has not classified hydrogen fluoride as to its human
effects or symptoms which would impair taking protective
carcinogenicity, and neither fluorides nor HF are listed by
action (ERPG-2), and 2 ppm as the maximum level below
IARC, NTP, OSHA, ACGIH, NIOSH, the State of California or
4
other governmental agencies as causing cancer. (31, 32, 33)
In animal studies, fluoride salts have caused effects in
Use ice cubes, not shaved ice, in order to
off-spring only at high, maternally toxic levels. Some animal
prevent frostbite.
studies have shown effects on male fertility, e.g. decreased
If immersion is not practical, towels should be soaked
sperm counts. (33) Fluoride exposures should be kept below
recommended levels to assure no adverse effects to the
with iced 0.13% benzalkonium chloride (Zephiran)
developing fetal skeletal system or teeth.
solution and used as compresses for the burned area.
Monitoring of urine for fluorides is an accepted method of
minutes. Do not use benzalkonium chloride (Zephiran)
Compresses should be changed every two to four
determining exposure. (34) Urine fluoride levels above 3
solution for burns of the eyes. Exercise caution when
mg/liter at the beginning of a workshift, or above 10 mg/liter
using benzalkonium chloride (Zephiran) solution near
at the end of a workshift, may indicate excessive absorption
the eyes as it is an eye irritant. Benzalkonium chloride
of fluoride. It should be noted that fluorides are often present
(Zephiran) soaks or compresses should be continued
in significant amounts in persons not occupationally exposed
until pain is relieved or until more definitive medical
(because of dietary sources of fluoride such as tea), and that
treatment is provided.
the urine fluoride determination is not specific for HF. (26)
b. Start massaging 2.5% calcium gluconate gel into
First Aid Treatment for
Hydrofluoric Acid Burns
the burn site.
Apply gel frequently and massage continuously until
pain and/or redness disappear or until more definitive
In Case of Contact or
Suspected Contact with HF:
medical care is given.
The individual applying the calcium gluconate gel should
SKIN CONTACT
wear surgical gloves to prevent a possible secondary
HF burn.
1. Move victim immediately under safety shower or other
water source and flush affected area thoroughly with
NOTE: Clinical experience has shown that both benza-
large amounts of running water. Speed and thoroughness
lkonium chloride (Zephiran) and calcium gluconate gel
in washing off the acid is of primary importance.
are effective when used correctly in appropriate
situations. In an animal model, benzalkonium chloride
2. Begin flushing even before removing clothing. Remove
(Zephiran) soaks are superior to calcium gluconate gel
all contaminated clothing while continuing to flush
under the experimental conditions used. (37, 38)
with water.
6. After treatment of burned areas is begun, the victim should
3. Rinse with large amounts of running water. If 0.13%
be examined to ensure there are no other burn sites which
benzalkonium chloride (Zephiran) solution or 2.5%
have been overlooked.
calcium gluconate gel are available, the rinsing may be
limited to 5 minutes, with the soaks or gel applied as soon
7. Arrange to have the victim seen by a physician. (If burns
as the rinsing is stopped. If benzalkonium chloride
are small and/or caused by weak acid, and treatment has
(Zephiran) or calcium gluconate gel is not available,
been provided by an experienced individual, evaluation by
rinsing must continue until medical treatment is rendered.
a physician may not be necessary.) During transportation
to a medical facility or while waiting for a physician to
4. While the victim is being rinsed with water, someone
see the victim, it is extremely important to continue the
should alert first aid or medical personnel and arrange
benzalkonium chloride (Zephiran) soaks or compresses
for subsequent treatment.
or continue massaging calcium gluconate gel. In many
situations, particularly for minor burns covering a small skin
5. Immediately after thorough washing, use one of the
area or for burns caused by dilute HF, continued treatment
measures below:
with soaks or gel may be effective as the sole type of medical
care. All persons with extensive burns or burns with significant
a. Begin soaking the affected areas in iced 0.13%
blister formation or with the appearance of whitish or dead
benzalkonium chloride (Zephiran) solution.
5
skin need to be seen by a physician. All persons with HF
treatment. If the person is wearing contact lenses, the
burns which do not respond to either calcium gluconate gel
lenses should be removed, if possible. However, flushing
or benzalkonium chloride (Zephiran) soaks or compresses
with water should not be interrupted, and the lenses should
within 30 minutes should be evaluated by a physician.
be removed by a person who is qualified to do so. If sterile
1% calcium gluconate solution is available, water washing
8. The physician may advise continuation of benzalkonium
may be limited to 5 minutes, after which the 1% calcium
chloride (Zephiran) soaks or calcium gluconate gel.
gluconate solution should be used to irrigate the eye using
a syringe or a continuous irrigation device.
a. If the physician advises continued treatment with
benzalkonium chloride (Zephiran) soaks or compresses,
2. Take the victim to a doctor, preferably an eye specialist, as
the soaks or compresses are usually required for 2 to 4
soon as possible. Ice water compresses may be applied to
hours. Significant relief of pain should be noted within
the eyes while transporting the victim to the doctor.
the first 30 minutes. If this does not occur, the victim
must be seen by a physician and more definitive care
3. If a physician is not immediately available, apply one or
instituted. If the pain is substantially relieved within the
two drops of 0.5% tetracaine hydrochloride, 0.5% propara-
first 30 minutes, continue the treatment for a total of 2
caine, or other aqueous, topical ophthalmic anesthetic and
hours. After that time, discontinue treatment and observe
continue irrigation. Use no other medications unless
for the recurrence of pain. If pain recurs, continue soaks
instructed to do so by a physician. Rubbing of the eyes is
or compresses until relief of pain occurs. Soaking for 6
to be avoided.
hours is sometimes needed. (Note: Because prolonged
immersion in the ice bath may result in discomfort, relief
INHALATION
may be obtained by removing the part from the bath
1. Immediately move victim to fresh air and get medical
every 10 minutes for a minute or so and then
attention.
reimmersing it. After the initial 30-60 minutes of
treatment, less ice can be used so the bath is cool
2. Keep victim warm, quiet and comfortable.
rather than cold.)
3. If breathing has stopped, start artificial respiration at once.
b. Calcium gluconate gel may be used for several hours or
4. 100% Oxygen should be administered as soon as possible
even repeated over a period of a few days. However, if
by a trained individual. Continue oxygen while awaiting
significant relief of pain does not occur within 30 to 40 min-
medical attention unless instructed otherwise by a physician.
utes, more definitive treatment such as Calcium Gluconate
injections or iced benzalkonium chloride (Zephiran) will be
5. A nebulized solution of 2.5% calcium gluconate may be
required. For small burns, or burns of the face, ears, and
administered with oxygen by inhalation.
near mucous membranes, calcium gluconate gel may be
6. Do not give stimulants unless instructed to do so by
very useful. The gel is applied frequently and massaged
a physician.
into the burned area. This is continued until relief is
obtained or further medical care is available.
7. The victim should be examined by a physician and held
under observation for at least a 24 hour period.
9. For serious burns, medical attention must be provided
as quickly as possible.
INGESTION
For minor burns, if first aid treatment does not alleviate
1. Have the victim drink several large glasses of water or milk
symptoms or if symptoms persist or recur, medical
to dilute the acid. Do not induce vomiting. Do not give
attention must be sought.
emetics or baking soda. Never give anything by mouth
to an unconscious person.
EYE CONTACT
2. Give several glasses of milk or several ounces of milk of
1. Immediately flush the eyes for at least 15 minutes with
magnesia, any calcium containing antacid®, Maalox®, etc or
large amounts of gently flowing water. Hold the eyelids open
grind up and administer up to 30 Tums™, Caltrate® or other
and away from the eye during irrigation to allow thorough
antacid tablets with water. The calcium or magnesium in
flushing of the eyes. Do not use the benzalkonium
these compounds may act as an antidote, however this has
chloride (Zephiran) solutions described for skin
6
not been supported in the literature (39).
3. Get immediate medical attention. Ingestion of HF is a
If immersion in the solution is not practical, soaked
life-threatening emergency.
compresses of the same iced solution should be applied
to the burned area. The immersion or compresses should
be used for at least two hours. Compresses should be
Medical Treatment for
Hydrofluoric Acid Burns
changed or soaked with additional solution approximately
every two to four minutes.
BURNS OF THE SKIN – GENERAL
If blisters are present, they should be opened and drained
and necrotic tissue should be debrided by a physician or
Burns from dilute acid are difficult to distinguish from other
qualified health care practitioner as soon as possible.
chemical burns and usually appear as areas of erythema.
However, immersion in benzalkonium chloride (Zephiran)
However, they may progress, if not treated, to areas of blistering,
or use of compresses should not be delayed if debridement
necrosis or ulceration. Burns from more concentrated acid
cannot be accomplished immediately.
have a characteristic appearance and present as severely
reddened, swollen areas with blanched, whitish regions which
Prolonged immersion in the iced benzalkonium chloride
rapidly progress to blistering and necrosis. A thick granular
(Zephiran) bath may result in discomfort due to excess
exudates usually appears under these blisters and requires
chilling; relief may be obtained by removing the burned part
debridement and removal.
from the bath every ten to fifteen minutes for a few minutes
and then reimmersing it when pain recurs. After the initial
Concentrated HF burns cause extreme pain. The pain is
30-60 minutes of treatment, less ice can be used so the bath
thought to result from nerve ending irritation due to increased
is cool rather than cold.
levels of potassium ions in extracellular spaces to
compensate for the reduced levels of calcium ions which
The success of this treatment is indicated by relief of the
have been bound by the fluoride. Relief of pain is an
severe pain in the burned area. If there is no significant relief
excellent indication of the success of treatment and,
of pain within 30 to 40 minutes, the use of 2.5 - 5% calcium
therefore, local anesthetics should be avoided.
gluconate injections may be necessary. If pain recurs when
the treatment is stopped at the end of the first two hours,
Many different types of therapies have been suggested for
immersion or compresses should be resumed until pain is
HF burns. The aim of all treatment is to chemically sequester
relieved. A total of four to six hours immersion or use of
the fluoride ion and to prevent extensive, deep-tissue
compresses of benzalkonium chloride (Zephiran) may be
destruction. (37, 38)
required for the treatment of most burns. No further iced
Zephiran treatment will be required in many instances. The
After treatment of recognized burned areas is begun, the
use of iced quaternary ammonium compound solutions offers
victim should be carefully examined to insure there are no
several advantages over topical calcium gluconate gel:
other burn sites which may have been overlooked.
• ability to treat burns on multiple surfaces, such
as the hand, more efficiently;
QUATERNARY AMMONIUM COMPOUNDS
• reduction of local pain;
Most HF burns can be satisfactorily treated by immersion of
• possible slowing of the rate of tissue destruction;
the burned part in an iced, aqueous solution of a quaternary
• possible slowing of the passage of the fluoride ion into
deeper tissues and into the bloodstream;
ammonium compound. Two solutions have been clinically
successful, 0.13% benzalkonium chloride (e.g. Zephiran)
• does not require continuous massaging.
or 0.2% benzethonium chloride. Because of its availability as
a non-prescription drug, benzalkonium chloride (Zephiran) is
Large burns, serious burns due to concentrated HF, or
recommended in the United States.
burns with delayed treatment will probably require the
use of calcium gluconate injections in addition to or
The solutions should be cooled with ice cubes. (Shaved or
instead of the benzalkonium chloride (Zephiran) soaks.
crushed ice may cause excessive cooling, with the danger
of frostbite.)
7
Quaternary ammonium compounds should not be used for
The physician should inject sterile 2.5 - 5% aqueous calcium
burns on the face, ears or other sensitive areas due to their
gluconate beneath, around and into the burned area.
irritating nature. It is preferable to use calcium gluconate
Calcium gluconate is packaged as a 10% solution, and
gel or calcium gluconate injection in these areas.
must be diluted 50:50 or 25:75 with normal saline to make
5% or 2.5% solutions. (Note: DO NOT USE calcium chloride,
CALCIUM GLUCONATE GEL
which is corrosive and may result in additional damage.)
Calcium gluconate gel, consisting of 2.5% USP calcium
If subcutaneous calcium gluconate injections are used,
gluconate in a surgical water soluble lubricant, is widely used
the amount injected initially is small and should not exceed
for first aid and/or primary treatment of HF burns of the skin.
0.5 cc per square centimeter of affected skin surface. The
The gel is convenient to carry and can be used to initially
injections should not distort the appearance of the skin. A
treat small burns that might occur away from medical care.
small-gauge needle (27-30 gauge) should be used, and the
(The gel is not recommended for burns with concentrated HF
burned area should be injected through multiple sites.
except as a first aid measure.) The gel is used by massaging
With successful treatment, pain relief following injection
it promptly and repeatedly into the burned area, until pain is
of 2.5% - 5% calcium gluconate solution is very rapid. The
relieved. If possible, surgical gloves should be worn during
patient can usually advise when the pain stops, and this
initial application of the gel, so the person providing treatment
is an indicator of adequate treatment. Multiple injections
will not receive a secondary HF burn. This treatment can be
in skin that has compromised integrity may increase the
started without waiting for medical direction. Several commer-
risk of infection, and the use of antibiotic creams such as
cially available calcium gluconate gel formulations have been
Silvadene® (silver sulfadiazine) or Garamycin® (gentamicin
evaluated and found to give comparable out comes. (35)
sulfate cream) should be considered following such
If used as the only method of treatment, liberal quantities of
they mask pain relief which is an important indication of
calcium gluconate gel must be massaged into the burned
adequacy of treatment.
treatment. Local anesthetics should not be used since
area continuously for up to several hours. Relief of pain can
be used to assess the efficacy of this treatment. If good relief
Some physicians prefer using calcium gluconate
of pain is not obtained after 30-40 minutes, alternate methods
injections initially as the primary treatment, instead
of treatment such as calcium gluconate injections or benza-
of using quaternary ammonium compound soaks or
lkonium chloride (Zephiran) soaks should be considered.
compresses or calcium gluconate gel. Injections often
are not necessary when there has been early and
The gel is especially useful for burns on the face, particularly
adequate treatment with soaks or gel.
near the mouth, eyes, on the ears, or for small, dilute acid
CALCIUM GLUCONATE SOLUTION
burns elsewhere. It may be convenient to use the gel for very
small burns where the victim can easily apply and massage
the gel into the burned area. Use of the gel may be more
In some instances, a 5% or 10% calcium gluconate solution
convenient for dilute acid burns such as occur with
may be used in compresses or for irrigation. For example,
commercial products like rust removers, aluminum
irrigating with a calcium gluconate solution may be the best
cleaners or etching solutions.
treatment should HF enter the external ear canal. In this
instance, referral to an otolaryngologist may also be needed.
CALCIUM GLUCONATE INJECTIONS
BURNS OF THE FINGERS AND NAILS
After first aid measures have been taken, injection of a
2.5% - 5% calcium gluconate solution is indicated as the primary
Burns of the fingers often create special problems in
medical treatment for large burns (over 25 square inches or
treatment. Finger and toe nails permit penetration of
160 square centimeters). For smaller burns, if benzalkonium
fluoride ions but prevent soaks or gels from being effective.
chloride (Zephiran) soaks or calcium gluconate gel do not
It may be necessary to drill, split or even remove nails to
result in significant relief of pain within 30 to 40 minutes,
allow the topical methods of treatment to be effective. One
injection of calcium gluconate solution is indicated. Injection
author has cautioned that removal of the nail should rarely
of calcium gluconate solution may also be indicated for
be necessary in the case of dilute HF acid (less than 10%)
burns in which treatment has been delayed.
burns. (40) The treating physician must consider the
8
morbidity associated with removal of the nail versus the
Following satisfactory placement of the arterial catheter,
digital subtraction arteriography was performed on all
need to treat the HF exposure.
patients in our series to identify the origin of vascular
supply to digits involved.
If immersion in benzalkonium chloride (Zephiran) solution is started immediately, it may be possible to avoid removing the nail.
Sometimes better penetration under the nail can be successfully
Once the tip of the arterial catheter was in the desired
accomplished by splitting the nail or by drilling several burr holes
location, a dilute preparation of calcium gluconate (10 ml
in the nail using a large gauge needle or a nail drill. If calcium
of a 10% solution mixed in 40 to 50 ml 5% dextrose) was
gluconate injection is used as treatment, the nail may still need to
infused with a pump apparatus into the catheter over four
be split or removed. If nail removal is necessary, using a short
hours. Each patient was observed closely during the
acting regional or ring-block anesthetic may facilitate this
infusion period for progression of symptoms and potential
procedure and not interfere with using pain relief as an indicator
complications of the procedure, such as alterations of
of effective treatment. When using calcium gluconate injections
distal vascular supply.
in the digits, care must be taken to inject the solution cautiously
so as to avoid compromising the circulation in these areas.
Following the four-hour infusion, the arterial catheter was
If benzalkonium chloride (Zephiran) soaks are not available,
underwent an observation period. If typical HF pain
maintained in place in the usual manner while the patient
experience has shown that some finger or hand burns can be
returned within four hours, a second calcium infusion
treated by using a glove filled with calcium gluconate gel.
was repeated until the patient was pain free four hours
Initially, calcium gluconate gel should be massaged into
following completion of the calcium infusion”. (14)
the burned area. Following this, an oversize surgical glove
should be partially filled with calcium gluconate gel, and the
There are now several reports of the successful use of
hand inserted into the glove. The gloved hand may be immersed
intravenous calcium gluconate to treat HF burns of the upper
in ice water, if available, which may aid pain relief. This
extremity. (41, 42, 43) Graudins, et al. describe their method:
treatment works best for burns where there is no blistering, or
after the burns have been debrided. As in other cases where
An intravenous catheter was placed on the dorsum of the
calcium gluconate gel is used, alternate methods of treatment
affected hand. The superficial veins were exsanguinated
should be considered if good relief of pain is not achieved
by elevation. A double-cuffed pneumatic tourniquet was
within 30 - 45 minutes. If pain is relieved, the glove should
applied above the elbow, inflated to 100 mm Hg above
systolic blood pressure, and 10 ml of 10% calcium
remain in place for three to four hours.
gluconate diluted with 30 to 40 ml of 0.9% saline solution
was then infused. Ischemia was maintained for 25 minutes;
INTRA-ARTERIAL AND INTRAVENOUS
CALCIUM INFUSION
the cuff was sequentially released over 3 to 5 minutes.
This Bier Block method was most successful for burns due
Reports in the literature have described the use of intraarterial injection or infusion of dilute calcium gluconate
to dilute acid. If the use of intravenous calcium gluconate
solutions to treat HF burns of the hand and digits. This
was not successful in relieving pain (which occurred with
method, although rather involved, should be considered in
burns due to 49% HF, the highest concentration seen in the
selected cases, especially where inadequate or delayed treat-
series of patients), Graudins et al. turned to intra-arterial
ment has occurred. The method is described as follows:
calcium gluconate infusion.
“A long catheter was inserted percutaneously into
ADDITIONAL MEASURES
the radial artery using standard aseptic technique.
Intra-arterial catheter placement was confirmed by
HF burns are very aggressive and it is extremely
pressure transducer and oscilloscope. If the burn involved
important that there be no delays during decontamination,
only the thumb, index,or long fingers, the catheter was
first aid or medical treatment. Assuring continuous care
advanced only a few centimeters proximally in preparation
after decontamination is critical to ensure a good result
for digital subtraction arteriography. If the burn involved
from medical treatment.
the ring or small fingers, the catheter was advanced
proximally into the brachial artery because access to the
ulnar circulation was necessary.
9
SYSTEMIC ABSORPTION AND METABOLIC EFFECTS
In instances of extensive burns, skin grafting has
occasionally been required, but the need for this treatment
should be markedly reduced by immediate and aggressive
Significant amounts of fluoride ion may be absorbed by skin
primary treatment.
contact, inhalation, or by ingestion. If systemic absorption
of fluoride occurs, hypocalcemia, hypomagnesemia and
Follow-up care requires monitoring to prevent secondary
hyperkalemia may also occur. All of these parameters need
infections. The use of daily dressings with antibiotic creams
to be monitored and appropriate therapeutic measures insti-
such as Silvadene or Garamycin has proven effective. HF
tuted. The patient should be observed for clinical signs of
burns may heal slowly, but if properly treated most heal with
hypocalcemia following ingestion or inhalation or following
little or no scarring in 14 to 28 days.
extensive burns greater than 25 square inches. Serum
calcium determinations must be performed immediately
ADDITIONAL AND UNPROVEN THERAPIES
and periodically to monitor and treat hypocalcemia. Severe
lowering of serum calcium levels can occur within one to two
The use of intravenous calcium gluconate is discussed
hours even with HF burns covering less than 2.5% of body
above. Both Williams, et al. (44) and Cox, et al. (45) have
surface area. (8) Continuous EKG monitoring to observe
discussed the use of intravenous magnesium sulfate to treat
prolongation of the Q-T interval may be useful to detect early
localized moderate to serious skin burns. Using either a rat
changes in serum calcium, although profound hypocalcemia
or a rabbit model, the authors administered intravenous
following HF exposure has been reported in the absence of
magnesium sulfate. Cox used a 0.2 mEq bolus over two
EKG changes or in the absence of other signs of tetany.
minutes, followed by a slower infusion of 0.2 mEq per hour
for four hours, with a total of 1.0 mEq/kg magnesium sulfate
The fall in serum calcium may occur precipitously following
administered. Williams administered 8 mg/kg over five
HF exposure. In two reported cases of exposure to anhydrous
minutes or 160 mg/kg over 10 minutes. These authors
HF, the serum calcium fell to levels around 3 milliequivalents
compare this dose to the amount of magnesium sulfate,
per liter (mEq/L) [normal = 8.8 - 10.3 mEq/L] within one to
infused more slowly, used in the treatment of eclampsia.
three hours of exposure. (8)
Dunn, et al. (37) have shown effectiveness of locally applied
If necessary, aqueous calcium gluconate may be given
calcium acetate solution, 10% in water at room temperature,
intravenously. Calcium gluconate as a 10% solution must be
in an animal model.
given slowly since excess calcium can produce vagal
Seyb et al. (47), performed an experiment in rats using a
fibrillation. The IV calcium gluconate should be repeated
bradycardia, ventricular arrhythmias and ventricular
topically applied solution of 50% aqueous dimethyl sulfoxide
until serum calcium levels return to, and remain at, normal
(DMSO) containing calcium gluconate (20% wt/vol). This
levels. In one fatal case, 280 mEq of calcium over four hours
treatment gave results comparable to injecting 10% calcium
was not sufficient to correct the profound hypocalcemia. (8)
gluconate or 10% magnesium sulfate, and was superior to
Without additional measures such as hemodialysis, it may
calcium gluconate gel in treating experimental HF burns.
not be possible to correct extreme hypocalcemia.
It should be noted that many of these therapies, while
Serum magnesium levels should also be monitored
promising, have been tested to a limited degree, if at all, in
and magnesium loss should be replaced intravenously if
humans. A product developed in France, “Hexafluorine” (46),
indicated. Yamaura, et al. have reported a case of HF
has been marketed in Europe and the United States for use
exposure in which prolonged QT interval occurred, in which
as a decontamination solution for HF skin and eye exposure.
ionized calcium levels were relatively high but the magnesium
Honeywell has conducted animal studies on this product with
level was low. (49) Serum potassium must also be carefully
equivocal test results. Scientific documentation of effective-
monitored. Significant elevations of serum potassium have
ness and experience with this product are lacking at this time
been noted in cases of fluoride toxicity and also in laboratory
and we therefore do not recommend its use (48).
studies. Hyperkalemia has also been implicated as a
causative factor in cardiovascular collapse, and should be
treated appropriately.
10
INHALATION INJURIES
Even with normalization of serum calcium and potassium, life
threatening ventricle arrythmia may occur, possibly due to a
direct toxic effect of the fluoride ion on the myocardium. (36).
Patients with inhalation exposures should also be
HEMODIALYSIS with fluoride free water (and normal to low
fluoride toxicity.
observed for signs of systemic absorption and
potassium and slightly higher calcium concentrations), in
conjunction with other treatments mentioned, should be
Exposure to hydrofluoric acid fumes can cause acute respirato-
considered in all cases of serious burns and may need to be
ry irritation, bronchospasm, and/or pulmonary edema.
repeated if indicated. (19, 20, 21) Serum fluoride levels
Medical personnel should also be alert to the possibility of
should be monitored. Normal plasma fluoride levels may
development of pulmonary edema when extensive burns of
differ because of various methodologies and analytical
the face, neck or chest have occurred. Intubation should be
techniques. The decision to use dialysis should be based on
avoided, if possible.
the HF exposure (concentration, body surface area) and the
clinical condition of the patient, including the serum levels of
The victim should be removed from exposure and administered
fluoride, calcium and potassium.
100% oxygen immediately. The use of 2.5% aqueous
Primary excision or surgical removal of tissue has been
with intermittent positive pressure, has been recommended.
calcium gluconate given by nebulizer with l00% oxygen, or
recommended by some practitioners as a method of reducing
Theoretically, this should reduce toxicity and damage from the
systemic absorption of fluoride. (50) While this could in some
fluoride ion and should be seriously considered in cases of
instances be life saving, it is a rather drastic measure. It is likely
inhalation exposure.
that renal dialysis could be used to effectively treat systemic
toxicity and would not result in the disfigurement, disability, or
Repeated use of nebulized calcium gluconate, every 4 hours
morbidity which could be associated with primary excision.
for 48 hours after a significant inhalation exposure, has been
described. (51)
EYE INJURIES
Burns of the oral mucosa or upper airway may cause severe
HF can cause severe eye burns, which, if not properly
swelling and necessitate a tracheostomy. It is, therefore,
treated, may result in scarring and blindness. The prognosis
recommended that all such patients be admitted to a hospital
is not good if first aid treatment is delayed or inadequate.
for observation.
After first aid treatment (see FIRST AID section) the following
medical treatment may be provided:
Because inhalation of HF may be associated with significant
If the individual wears contact lenses, it is usually best to
should be administered as necessary. Even in the absence
bronchospasm, inhaled, oral or parenteral bronchodilators
remove the lenses before additional eye irrigation.
of symptoms, the prophylactic administration of inhalational
steroids (e.g. beclomethasone dipropionate) may be
Mix 50 ml of 10% calcium gluconate with 500 ml of normal
indicated. (21) Pulmonary function testing may be helpful in
saline to give approximately a 1% calcium gluconate solution.
assessing the degree and progress of pulmonary injury.
After administering local anesthetic eye drops, use an eye
clamp and IV infusion set or a two pronged nasal oxygen
Specific measures may be needed to treat pulmonary edema.
cannula to instill the solution over a period of one to two
hours. Other irrigation devices, such as a Morgan Lens may
be utilized as well. More prolonged use of the solution could
possibly damage the cornea. Consult an ophthalmologist
regarding additional treatment.
11
INGESTION INJURIES
containing antacid. The Lavage tube must be passed with
After first aid is completed (drinking several glasses of water
corrosive effects is the same as for ingestion of other strong
followed by two glasses of milk or two ounces of milk of mag-
acids. Systemic toxicity is very likely to occur and
nesia, or other calcium or magnesium containing antacids),
may require aggressive treatment.
care to prevent perforation. Treatment for the
the stomach may be lavaged with a solution of a calcium
12
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Inc., 1998.
5. Upfal, M. and Doyle, C.: Medical Management of Hydrofluoric Acid
Exposure. J Occup Med 32: 726-731, August, 1990.
32. www.dir.ca.gov/oshsb/airborn_contaminants_2011.html
6. Caravati, E. M.: Acute Hydrofluoric Acid Exposure. Am J Emerg Med 6:
143-50, March, 1988.
33. Chemical Substances Bureau, The Netherlands. Hydrogen Fluoride, Risk
Assessment. Draft, 12 August, 1997 (with changes 24 November, 1997).
7. ATSDR: Managing Hazardous Materials Incidents. Medical Management
Guidelines for Acute Chemical Exposure: Hydrogen Fluoride. 2011.
34. Kono, K., et al.: Urinary Fluoride Monitoring of Industrial Hydrofluoric Acid
Exposure. Environ Res 42:415-20, April 1987.
8. Tepperman, P. B.: Fatality Due to Acute Systemic Fluoride Poisoning Following
a Hydrofluoric Acid Skin Burn. J Occup Med 22:691-2, October, 1980.
35. Roblin I. et al.: Topical Treatment of Experimental Hydrofluoric Acid Skin
Burns by 2.5% Calcium Gluconate. J Burn Care Res 2006; 27(6):889-94.
9. Wetherhold, J. M.: Treatment of Hydrofluoric Acid Burns. J Occup Med
7:193-5, May, 1965.
36. Vohra, R. et al.: Recurrent Life-Threatening Ventriculose Dysrhythmia
Associate with Acute Hydrofluoric Ingestion; Observations in One Case and
Implications for Mechanism of Toxicity. Clinical Toxicology 2008;46,79-84.
10. MacKinnon, M. A.: Hydrofluoric Acid Burns. Dermatologic Clinics 6(1)67-74,1988.
37. Dunn, B. J., et al.: Hydrofluoric Acid Dermal Burns: An Assessment of Treatment
Efficacy Using an Experimental Pig Model. J Occup Med 34:902-9, 1992.
11. Reinhardt, C. F.: Hydrofluoric Acid Burn Treatment. Am Ind Hyg Assoc J
27:166-171, l966.
38. Dunn, B. J., et al.: Topical Treatments for Hydrofluoric Acid (HF) Dermal
Burns: Further Assessment of Efficacy Using an Experimental Pig Model.
J Occup Environ Med 38: 507-14, 1996.
12. Browne, T. D.: The Treatment of Hydrofluoric Acid Burns. J Soc. Occup Med
24:80-9, July, 1974.
39. Heard, K. and Delgado, J.: Oral Decontamination with Calcium or
Magnesium Salts Does Not Imporve Survival Following Hydroflouric Acid
Ingestion. J Toxicol Clin Toxicol 41(6)789-92,2003.
13. Rose, L. and Trevino, M. A.: Further Evaluation of Hydrofluoric Acid Burns
of the Eye. J Occup Med 26:483-4, July, 1984.
14. Vance, M. V.: Digital Hydrofluoric Acid Burns: Treatment with Intra-arterial
Calcium Infusion. Ann Emer Med 15:59-65, August 8, 1986.
40. Roberts J. R. and Merigian, K. S.: Acute Hydrofluoric Acid Exposure (letter).
Am J Emerg Med 7:125-6, January, 1988.
15. Davanzo, F. et al.: Hydrofluoric Acid Intoxication: A New Therapy. Med Lav
78:333-6, 1987.
41. Henry, J. A. and Hla, K. K. Intravenous Regional CalciumGluconate
Perfusion for Hydrofluoric Acid Burns. Clin Toxicology 30:203-7, 1992.
16. Boink, A. B. T. J.: Pathophysiological Mechanisms of Hydrofluoric Acid and
Fluoride Intoxication: An Explorative Study in Rats and Pigs. Thesis. University
of Utrecht, The Netherlands. 1993.
42. Graudins, A., et al.: Regional Intravenous Infusion of Calcium Gluconate for
Hydrofluoric Acid Burns of the Upper Extremity. Ann Emerg Med 30:604-7, 1997.
17. McIvor, M. E.: Delayed Fatal Hyperkalemia in a Patient with Acute Fluoride
Intoxication. Ann Emerg Med 16:1166-7, October, 1987.
43. Ryan, J.M. et al.: Regional Intravenous Infusion of Calcium Gluconate for
Hydrofluoric Acid Burns of the Upper Extremity. Ann Emerg Med 31:526-7, 1998.
18. Cummings, C. and McIvor, M. E.: Fluoride Induced Hyperkalemia: The Role
of Ca2+ Dependent K+ Channels. Am J Emerg Med 16:1-3, January, 1988.
44. Williams, J. M. et al.: Intravenous Magnesium in the Treatment of
Hydrofluoric Acid Burns in Rats. Ann Emerg Med 23:464-9, 1994.
19. Björnhagen, J. et al.: Hydrofluoric Acid - Induced Burns and Life
Threatenting Systemic Poisoning - Favorable Outcome After Hemodialysis.
J Toxicol Clin Toxicol 41(6):855-60,2003.
45. Cox, R. D. and Osgood, K. A. Evaluation of Intravenous Magnesium Sulfate
for the Treatment of Hydrofluoric Acid Burns. Clin Toxicology 32:123-36, 1994.
46. Hexafluorine Product Literature, DH Marketing, Tarrytown, NY. 1993.
20. McIvor, M. E.: Acute Fluoride Toxicity: Pathophysiology and Management.
Drug Saf 5:79-85, 1990.
47. Seyb, S. T.: A Study to Determine the Efficacy of Treatments for Hydrofluoric
Acid Burns. J Burn Care Rehabil 16:253-7, 1995.
21. CTEF (Comité Technique Européan du Fluor, a sector group of CEFIC):
Medical Management of Hydrogen Fluoride Injuries. February 2004.
48. Hulten, P. et al.: Hexafluorine vs Standard Decontamination to Reduce
Systemic Toxicity After Dermal Exposure to Hydrofluoric Acid. J Toxicol Clin
Toxicol 42(4)355-61,2004.
22. Hazardous Substances Data Bank (HSDB): Sodium Fluoride., National
Library of Medicine, 1992.
49. Yamaura, K. et al.: Recurrent Ventricular Tachyarrythmias Associated with
QT Prolongation Following Hydrofluoric Acid Burns. Clin Toxicol 35:311-3, 1997.
23. Gaugl, J.F. and Woolridge, B.: Cardiopulmonary Response to Sodium
Fluoride Infusion in the Dog. J Toxicol Environ Health 11:765-82, 1983.
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Acid Burns. J Occup Med 30:873-4, November, 1988.
24. Strubelt, O., et al.: The Pathophysiological Profile of the Acute
Cardiovascular Toxicity of Sodium Fluoride. Toxicology 24:313-23, 1982.
51. Tsonis, L. et al: Hydrofluoric Acid Inhalation Injury. J Burns Care Res 2008;
29:852-855.
25. US Department of Labor (OSHA): CFR 1910.1000, Table Z-2.
52. Gradinger R. et al: Toxic Myocarditis Due to Oral Ingestion of Hydrofluoric
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13
ingredients may be readily available. In addition, the
Appendix
ingredients may be stored separately until needed, and
shelf life is less of a concern.
FIRST AID AND MEDICAL SUPPLIES
In an emergency calcium gluconate gel (2.5% calcium
The following supplies should be maintained in a dispensary
gluconate in a water soluble base) may also be formulated
or first aid station near hydrofluoric acid handling and storage
by a pharmacist by dissolving 3.2 grams of calcium
areas:
gluconate USP in 5 cc of sterile water, and then mixing with
120 cc (4 oz. tube) of K-Y® Jelly or other water soluble
1. Benzalkonium chloride (Zephiran) solution*
lubricant (2.5 grams per 100 cc lubricant).
a. For soaks and compresses, 3 to 4 gallons of 0.13%
3. Aqueous calcium gluconate, 10% USP, 10 cc ampules
water solution of benzalkonium chloride (Zephiran). The
(4.5 mEq calcium or 93 mg elemental calcium per 10 cc)
0.13% solution is available as a non-prescription drug in
gallon containers. The solution should be obtained in
a. To make calcium gluconate gel, or
advance. It should replaced before the expiration date
on the label. It is recommended that it be stored in
b. To mix with sterile saline for eye irrigation (5 ampules
properly labeled light-resistant containers.
10% calcium gluconate per 500 cc sterile normal saline
for a 1% solution), or
Benzalkonium chloride (Zephiran) is also available as a
17% solution. If this concentrate is used to make a 0.13%
c. To mix with sterile saline for administration with oxygen
(1:750) solution, the dilution should be performed by a
by nebulization (10 cc 10% calcium gluconate in 30 cc
qualified individual, such as a registered pharmacist. The
sterile saline for a 2.5% solution), or
shelf life of the diluted solution is uncertain, and it should
be replaced annually.
d. To be administered by a physician. When injected subcutaneously, 10% calcium gluconate must be diluted 50:50
Benzalkonium chloride (Zephiran) should be available
or 25:75 with normal saline to make 5% or 2.5% solutions.
as a non-prescription drug through most local pharmacies. The local pharmacies obtain it from pharmaceutical
4. Sterile 0.9% saline
wholesale distributors.
a. Vials, (e.g. 10 cc, 30 cc, or 50 cc) to dilute 10% calcium
In addition to benzalkonium chloride (Zephiran),
gluconate to 2.5% - 5% for injection, or to 2.5% for
benzethonium chloride (Hyamine 1622®) has also been
nebulization.
used successfully to treat HF burns. Because of its
availability as a nonprescription drug, benzalkonium
b. 500 cc IV to dilute 10% calcium gluconate to 1% for
chloride (Zephiran) is recommended.
eye irrigation.
b. Ice cubes (not crushed or shaved ice).
5. 0.5% tetracaine hydrochloride solution to counteract
blepharospasm and facilitate eye irrigation.
c. Assorted basins (for immersing burned areas in
benzalkonium chloride (Zephiran solution).
6. Medical oxygen
d. Towels (for use as wet compresses).
7. Nebulizer, to administer 2.5% calcium gluconate with oxygen.
2. Calcium gluconate gel, 2.5%
8. Beta adrenergic bronchodilators and steroids
for inhalation.
Calcium gluconate gel is available commercially.
9. Surgical gloves
It may also be made by mixing one ampule of 10% calcium
gluconate solution for each ounce of a water based
10. Syringes and needles (27-30 gauge).
lubricating jelly (e.g., K-Y® Brand Lubricating Jelly) using
40 cc per 4 ounce tube. This has the advantage that the
14
NOTES
The FIRST AID AND MEDICAL TREATMENTS AND SUPPLIES
recommended in this brochure are based on information
reported in the medical literature and the personal experience
Caltrate® is a Registered Trademark of Wyeth Consumer
of Honeywell physicians. It should be noted that there are no
Healthcare, Madison, NJ 07940
medications in the U.S. for which the specific indication is the
treatment of HF burns. The physician has the dilemma of
Garamycin® is a Registered Trademark of Fera
using prescription drugs in a non-approved manner, or of
Pharmaceuticals LLC, Locust Valley, NY 11560
using substances which are not approved drugs but which
have been proven effective for medical treatment. Given the
Hyamine® is a Registered Trademark of Rohm and Haas
choice between recommending effective treatment, or
Company, Philadelphia, PA 19106
recommending the use of only drugs which are approved,
we have chosen to recommend the effective treatment.
K-Y® Brand Lubricating Jelly is a Registered Trademark of
Johnson & Johnson Products, Inc., Skillman, NJ 08558
Benzalkonium chloride (Zephiran) is available in the U.S. as
a non-prescription drug. It is a surface active agent sold for
Maalox® is a Registered Trademark of McNeil Consumer
use as a disinfectant. It is available in a 1:750 (0.13%)
Pharmaceuticals Co., Fort Washington, PA 19034
aqueous solution, a 17% concentrate, and a tinted tincture.
The concentrated 17% solution must be diluted. The tinted
Silvadene® is a Registered Trademark of King Pharmaceuticals
tincture is not recommended to treat HF exposures.
Research and Development Inc. Cary, NC 27513
CALCIUM GLUCONATE INJECTION, USP (one gram in 10 ml,
Tums® is a Registered Trademark of Glaxo SmithKline
10% solution) is labeled for intravenous use only. Experience
Consumer Healthcare, L.P., Pittsburgh, PA 15230
has shown that when diluted to 2.5% - 5% with normal saline,
and used as described in this brochure, it is a safe and
Zephiran® is a Registered Trademark of Sanofi- Aventis US
effective treatment for HF skin exposure. When diluted to
LLC, Bridgewater, NJ 08807
2.5% and used as described, it is safe for nebulization and
inhalation, and when diluted to 1.0% and used as described, it
is safe for eye irrigation.
15
16
Honeywell Hydrofluoric Acid
HF Products
For additional information
Hydrofluoric Acid Treatment
Quick Reference Chart
FOLD OUT HERE
For additional assistance, including
technical information covering all
aspects of hydrofluoric acid, safe
handling, use and disposal write:
Honeywell Performance Materials
and Technologies
Fluorine Products
101 Columbia Road
Morristown, NJ 07962-1053
This booklet describes the special First Aid and Medical Treatment measures
necessary following exposure to or injury from HYDROFLUORIC ACID (HF).
In the event of a medical emergency
with this product, call the 24-hour
However, it must be emphasized that
Honeywell emergency telephone number:
800-498-5701
PREVENTION
of exposure or injury must be the primary goal.
To place an order, obtain prices or product availability information, call toll-free:
Preventive measures include:
From within the continental United States
800-522-8001
1. Making everyone who handles or uses HF aware of its properties
973-455-6300
and dangers.
From any location in Canada
2. Training everyone who uses HF in proper handling and safety precautions.
800-553-9749
3. Utilizing all appropriate engineering controls, and making sure that the
controls are maintained and functioning properly.
4. Requiring everyone who handles or uses HF to have available the proper
safety and personal protective equipment, to be trained to use the
equipment, and to always use the equipment when necessary.
5. Arranging ahead of time to provide first aid or medical treatment
Recommended Medical Treatment
for Hydrofluoric Acid Exposure
measures if necessary.
If you have questions, comments or suggestions, please write to:
Technical Service Manager - Hydrofluoric Acid
Honeywell Performance Materials and Technologies
101 Columbia Road
Morristown, New Jersey 07962-1053
Honeywell Performance Materials
and Technologies
101 Columbia Road
Morristown, NJ 07962
Toll Free: 1-800-622-5002
Fax: 1-973-455-6141
www.honeywell.com/hfacid
FP-003
DISCLAIMER: All statements, information, and data given herein are
believed to be accurate and reliable but are presented without guaranty, warranty, or responsibility of any kind, express or implied.
Statements or suggestions concerning possible use of our products
are made without representation or warranty that any such use is free
of patent infringement and are not recommendations to infringe any
patent. The user should not assume that all medical and first aid
measures are indicated or that other measures may not be required.
October 2012
Printed in USA
© 2012 Honeywell International Inc.
All rights reserved